(Per a decision of the Ambulatory Policy Committee, effective July 1, 2008)
What must be dictated:
1. Pre-op H&Ps: if the patient is being admitted post-op or if the patient is medically or psychosocially complex.
2. Consults:
A) Assessment and plan for all initial consults
B) Consult notes when there is a significant change in diagnosis, patient status or plan
C) All consults done on referrals from CPN providers
3. Transfers:
A) All transfers to another site or institution (i.e. hospital, ED, L&D for eval)
B) Planned transfers of care from one clinician to another
4. Surgical pre-op note by the surgeon including the indications, type of surgery and anesthesia
What is highly recommended to dictate:
All consults
All consult requests except very routine ones (i.e. for eyeglasses, screening flex sig, optho for diabetes screening)
Behavioral and medication contracts
Progress notes for medically or psychosocially high risk or complex patients on presentation and at each significant change in status
Progress notes for patients who are routinely followed at more than one site
Clinical notes for Anticoag clinic patients if they are seen at another site and have new illnesses/medications that could affect their coagulation studies
Management of critical abnormal test results called to a provider outside of the hospital
(last updated by Tai, May 2008, per an email from Chris Farnitano, May 29, 2008)
Dictation Policy
(Per a decision of the Ambulatory Policy Committee, effective July 1, 2008)What must be dictated:
1. Pre-op H&Ps: if the patient is being admitted post-op or if the patient is medically or psychosocially complex.
2. Consults:
3. Transfers:
4. Surgical pre-op note by the surgeon including the indications, type of surgery and anesthesia
What is highly recommended to dictate:
(last updated by Tai, May 2008, per an email from Chris Farnitano, May 29, 2008)